Please (1) Print this form. (2) Use a pen to fill the form. (3) Fax the form. Thank you.
CIAX.COM
CIAX.COM, 5 LONGHEY RD, MANCHESTER, M22 8UA, UNITED KINGDOM
Tel: +44 161 902 0980 Fax: +44 161 945 8169 Email: helpCIAX.com

FAX: 0161 945 8169

 
ORDER NUMBER: DATE:

ADDRESS: Must be the billing address of the credit card

CONTACT: COMPANY:
ADDRESS:
CITY: POST CODE / ZIP:
TEL: FAX:
EMAIL: <<< IMPORTANT: Email address for delivery of software
ORDER CODE PRICE QUANTITY SUB-TOTAL
    
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VAT (17.5%):

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TOTAL:

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CREDIT CARD NUMBER:  [  ] VISA  [  ] MASTERCARD  [  ] ACCESS  [  ] SWITCH  [  ] AMERICAN EXPRESS
                                                 
SECURITY: Last 3 digits (or 4 digits) printed on back of your card, printed on the Authorised Signature strip usually.
                 

VALID FROM DATE: (Example: 04 / 2004)

EXPIRY DATE: (Example: 06 / 2005)

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SWITCH ISSUE NUMBER: (For SWITCH cards only)

           

CARD HOLDER'S NAME:

CARD HOLDER'S SIGNATURE: